A scalable solution for delivery of Diabetes Self-Management Education in Thailand

Type 2 diabetes is a leading health problem in Thailand, with over 4 million adults living with the chronic condition in 2015. If the disease is not managed properly, it can lead to severe complications (e.g. heart disease, kidney disease, loss of sight) and even death. In addition, there are steep costs to the Thai economy - treating diabetes and its complications consumes over 10% of all healthcare spending, and many people with diabetes have to stop work due to the condition.
To successfully manage diabetes and prevent its negative consequences, education and lifestyle counselling are prescribed as standard in many countries, supported by research evidence. Such programs (known as Diabetes Self-Management Education, DSME) help people by giving them motivation and skills to lead a healthier lifestyle, monitor warning signs for complications, follow complex medication regimes, and manage the stress of having diabetes. In Thailand, people suffering from diabetes are not currently offered any DSME services by the national health system, which means that management of diabetes is poor and rates of complications are high. The reason for this gap in service is partly the lack of a DSME program proven to work in Thailand, but also government concerns over affordability and feasibility of offering such a program at national level.
To overcome these barriers, we propose to develop a new low-cost DSME program for people living with diabetes in Thailand, test that it works in a trial, and also find out how it can be made affordable for the government to provide it to everyone.
The DSME program will be delivered as monthly meetings led by community health volunteers and nurses, aided by a short films about living with diabetes, to introduce key topics. These films will be produced in Thailand featuring real patients, in collaboration with award-winning charity Medical Aid Films (www.medicalaidfilms.org). The education and skills training will be followed by an open discussion session to discuss common challenges and solutions, set lifestyle goals and seek advice. We will develop the content of the DSME program through working closely with health care workers and patient groups, testing our initial version and refining it, based on observing what works and what doesn't work. Then we will test its effectiveness in a trial, by randomly assigning 15 community hospitals to offer all newly diagnosed persons either a) DSME program delivered by community health volunteers, b) DSME program delivered by nurses, or c) usual care (no DSME program). After one year, we will compare the control of blood glucose and risk of heart disease between patients of hospitals with and without the DSME program. We predict that in hospitals receiving the DSME program, management of diabetes will be better than in those without any program, and that both nurses and community health volunteers will be able to deliver it effectively.
Alongside the main trial, we will collect data from participants and health care workers (through interviews) on their responses to the program and why and how it helped to improve diabetes management. Understanding these processes is vital to be able to adapt the program for other countries, making use of lessons learnt in Thailand. We will collect data on the costs involved with each part of the DSME program, and use it to identify the most affordable way of providing DSME in the Thai health system (we suspect it will be DMSE provided by community health volunteers). We will summarize all these results into policy recommendations, to be used by our collaborators at the Ministry of Public Health to decide whether and how to deliver the DSME program to the whole country. If adopted, the program has huge potential to improve the lives of people with diabetes and contribute to Thailand's continued economic growth and development.

Type 2 diabetes is amongst the foremost challenges facing policy makers in Thailand, accounting for considerable death, disability and healthcare expenditure. Under Thailand's strong primary health system, medical management of diabetes is widely available. However, control of blood glucose and other cardiovascular disease risk factors, and regular screening for early detection of complications remain low due to a lack of services for education and counselling to support behavioural changes necessary for good self-management of the condition. A substantial literature documents the effectiveness of Diabetes Self-Management Education (DSME) programs for improving diabetes outcomes, although little high quality data are available in Thailand, and traditional delivery models (health-professional led one-to-one or small-group sessions) are unlikely to be scalable in Thailand given current human resource and budgetary constraints. Thus we propose to develop a low-cost DSME program and scalable delivery model for roll-out within the Thai primary care system. The intervention will be based on behaviour-change and social support theories, delivered in monthly group meetings by lay health workers or nurses, and aided by a suite of short films to introduce key topics and stimulate discussion. We will randomise 15 community hospitals to offer to those newly diagnosed with diabetes DSME delivered by lay health workers, nurses (for comparative effectiveness), or usual care. After 12 months, we will compare glycaemic control and cardiovascular risk scores between the three arms. We will conduct cost-effectiveness, process and policy evaluations to produce best-buy recommendations for the Thai Ministry of Public Health.

The proposed study has the potential to make a positive impact on Thai society as well as international policy though the strong links between academics from leading universities in Thailand and the United Kingdom as well as high ranking policy makers in the Ministry of Public Health, Thailand.
Under Thailand's universal health coverage, nearly everyone diagnosed with diabetes receives timely medical care (>97%) and has access to screening. Yet, surveys suggest that only about half of the people with diabetes achieve optimal control of risk factors or get annual screening for microvascular complications. Having a package of 'best-buys' for delivering a culturally-tailored DSME program in Thailand that is proven to be clinically effective and cost-effective will have direct and indirect impacts on Thai Society in many ways:
The first beneficiaries of the intervention will be the people receiving it, as a large body of evidence supports the effectiveness of DSME for improving self-management of diabetes and quality of life. This leads to a reduction in complications associated with diabetes and therefore improved health and productivity. A senior Thai policy maker and co-investigator on this project has expressed strong commitment to full-scale implementation of an effective model for DSME, in recognition its society-wide impact on reduction of diabetes complications, improved population health and economic productivity in Thailand.
A technology driven method, such as the use of film to disseminate knowledge and provoke discussion as proposed in this study is in line with the Thai National Policy that promotes the application of technology in health care services. Films are designed to be low-cost and highly scalable, generating a model for fruitful interaction of both provider and patients. Success of such models is also likely to spur other related models of health-care delivery.
The second beneficiary of the project are the providers in the Thai health care system. Our standard package will include training materials for providers which can strengthen the capacity of the Thai primary care network in counselling and disease management techniques. These skills are also transferable to a number of other chronic conditions where patients may benefit from receiving proper counselling and self-management education. An indirect impact for the providers are that they will also have improved capacity to self-manage their own behavioural risk factors or conditions.
A scalable solution for delivery of DSME will also have a profound effect in helping to reduce health inequalities in Thailand. In the Thai healthcare system, structured DSME is not routinely available. Concerns about the burden on existing staff and cost have so far prevented the introduction of DSME in many settings, meaning brief education sessions are usually only offered in large universities or medical schools, exacerbating existing rural-urban inequalities in healthcare access. The negative health and economic impacts of diabetes disproportionately affect poor and marginalised groups, who will be reached through roll-out of DSME in all Thai primary networks. The intervention will be designed to be accessible and effective among these high-risk groups, for example through use of films as a delivery method and the focus on learning core transferrable skills for self-management (self-efficacy, problem solving).
Lastly, lessons learned from conducting the project in Thailand can be shared across different countries, especially within the South-East Asia region where Thailand are seen as leaders in progressive health policies, especially those with fewer resources for evaluation of their own programs (e.g. Lao PDR, Indonesia, and Myanmar).